New ESMO guideline on managing cancer-related breathlessness

  • Eur Urol

  • Oncology guidelines update
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The European Society for Medical Oncology (ESMO) has issued new guidance on the management of breathlessness in patients with cancer.

Key recommendations in the guidance include the following:

Assessment

  • Patient-reported outcomes are the gold standard for assessment of breathlessness. Physiological assessments may complement but not replace patient reports (III B).
  • Screen for breathlessness routinely at all inpatient and outpatient clinical encounters (III B).
  • Routine screening should include a unidimensional scale of choice and activities that patients have stopped or reduced because of breathlessness (III B).
  • Patients with chronic breathlessness should have a fuller assessment (IV B).
  • For patients with episodic breathlessness, ask about intensity, frequency, duration, impact, and potential triggers (IV B).

Underlying conditions

  • Identify and treat potentially reversible condition(s) contributing to breathlessness (II A).

For the management of conditions contributing to breathlessness, the following guide can be used.

Anaemia (symptomatic): Consider transfusion if haemoglobin

Asthma/COPD exacerbation: Medical optimisation.

Cachexia: Consider referral to palliative care, dietician, and/or physical therapy.

Central airway obstruction: For proximal lesions, consider endobronchial interventions, tumour ablation, and airway stent placement. For distal lesions, consider radiotherapy.

Chemotherapy-induced pulmonary toxicities: Withhold treatment and consider corticosteroids.

Immunotherapy-induced pulmonary toxicities: Withhold treatment and consider corticosteroids.

Heart failure exacerbation: Medical optimisation.

Lymphangitic carcinomatosis: Treat underlying malignancy. Consider corticosteroids (anecdotal).

Malignant ascites: Paracentesis with/without indwelling catheter.

Malignant pleural effusions: For patients with a short-life expectancy (

Malignant pericardial effusion/tamponade: Pericardiocentesis, pericardiectomy with/without pericardial window.

Metabolic acidosis: Identify and treat the underlying cause.

Pneumonia: Anti-infective agents.

Pulmonary embolism: Anticoagulation.

Radiation-induced pneumonitis or fibrosis: Consider corticosteroids.

Superior vena cava syndrome: Treat underlying malignancy. Consider corticosteroids (anecdotal).

Tumour embolism: Treat underlying malignancy.

Non-pharmacological interventions

  • Consider use of a hand-held fan directed to the face. This may be useful alone in people without hypoxaemia, or as an adjunct to oxygen supplementation (II B).
  • Advise patients on breathing retraining techniques and/or refer to specialist services (II B).
  • Consider a trial of a mobility aid to assess possible impact on breathing during ambulation and functional activities (II B).
  • Educate and inform patients on self-management strategies (II B).
  • Refer patients to exercise-based rehabilitation programmes (I,A).
  • Provide individualised advice on aerobic and resistance exercises (II B).
  • Consider a therapeutic trial of acupressure or acupuncture (II C).

Pharmacological interventions

  • Regular, oral, low-dose morphine is the first-line pharmacological treatment for severe chronic breathlessness that persists despite non-pharmacological measures (II B).
  • In opioid-naïve patients, a starting daily dose of scheduled morphine 10-30 mg over 24 hours can be used, with individual titration (II B).
  • In opioid-tolerant patients, an increase in the baseline dose of opioid by 25%-50% may be considered (V C).
  • Consider prophylactic use of opioids in opioid-tolerant patients with severe exertional breathlessness associated with defined triggering situations leading to significant functional impairment and/or distress despite standard treatments. Patients should use prophylactic doses sparingly (≤2/day) and only with close monitoring (II C).
  • All patients starting opioids should be offered prophylaxis laxatives and antiemetics as needed (I A).
  • Patients should be educated on safe opioid use and monitored longitudinally with risk mitigation strategies (III A).
  • Benzodiazepines should not be used as first-line pharmacological therapy (III D).
  • Benzodiazepines may be used with caution for breathlessness with associated anxiety if opioids are ineffective (V C).
  • In the last days of life, benzodiazepines may be considered for palliative sedation in patients with refractory breathlessness (IV C).
  • Consider corticosteroids for palliation of breathlessness refractory to other treatments (II C).
  • Palliative oxygen is not recommended in patients with resting SpO2 ≥90% (II D).
  • High-flow oxygen may be considered, especially if the patient has hypoxaemic respiratory failure (II B).
  • Consider a trial of noninvasive ventilation in patients with severe chronic breathlessness, especially in patients with acute hypercapnic respiratory failure (II B).
  • Sertraline is not recommended (II D).
  • The use of other antidepressants for breathlessness should be limited to the clinical trials context (V C).
  • Cannabinoids are not recommended (IV D).

Multimodal interventions

  • Patients should be referred to specialist multimodal breathlessness services if available (I A).
  • Refer to palliative care services if holistic breathlessness services are not available (II B).

Caregivers

  • Routinely assess the psychological status, information needs, and support network for carers (III B).